Treatment Outcomes for Tuberculosis Infection and Disease Among Persons Deprived of Liberty, Uganda, 2020

We report that unsuccessful treatment outcomes were 11.8% for tuberculosis (TB) disease and 21.8% for TB infection among persons deprived of liberty in Uganda Prisons Service facilities. Remedial efforts should include enhancing referral networks to ensure treatment continuity, strengthening data systems for complete outcome documentation, and prioritizing short-course treatment regimens.


DISPATCHES
T uberculosis (TB) remains a major public health challenge and the most frequent cause of illness and death among persons living with HIV (PLHIV) (1).Globally, TB occurs in congregate settings marked by malnutrition, overcrowding, underlying illnesses or conditions such as HIV, and poor ventilation, which include correctional facilities (2)(3)(4).High TB prevalence in prisons contributes to illness and death not only among persons deprived of liberty (PDLs; e.g., persons who are incarcerated or otherwise being held in detention facilities) but also among the general population who interact with PDLs in prison or after a PDL's release (3).
In 2020, the Uganda Prisons Service housed ≈65,000 PDLs across 259 facilities.The average stay was 19.1 months for capital offenders and 3.6 months for petty offenders.In Uganda, TB incidence was estimated to be 2,071/100,000 persons in prisons in 2019 (5).All PDLs are screened at entry into Uganda Prisons Service facilities for TB disease and HIV status to establish eligibility for TB preventive treatment (TPT).Case finding during incarceration is determined from symptom self-reporting.Since 2016, the treatment regimens recommended by the Uganda Ministry of Health have been isoniazid, rifampin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid/rifampin for 2 months for TB disease and 6 months of isoniazid for TB infection (TBI).However, 2019-2021 Uganda Prisons Service data indicated suboptimal treatment outcomes for those regimens; the TB disease treatment success rate was 89% and cure rate was 65%, and TPT completion rate was 75% (6).To inform remedial interventions, we conducted a cross-sectional study to evaluate correlates of unsuccessful treatment outcomes for TB disease and TBI among PDLs in Uganda.

The Study
In December 2021, we extracted data on PDLs who received TB disease or TBI treatment during January-December 2020 at 27 prisons that were selected according to availability of TB and HIV services at those sites (Appendix Figure, https://wwwnc.cdc.gov/EID/article/30/7/23-0611-App1.pdf).We abstracted sociodemographic and clinical information (age, sex, HIV status, incarceration stay, treatment initiation date, and outcome) from prison entry, TPT, and unit TB registers.TB disease data collected from unit TB registers were TB treatment history (new, previously treated), diagnosis (laboratory confirmed, clinical), and site (pulmonary, extrapulmonary) (7).We calculated the duration of prison stays before initiation of TB disease or TBI treatments.For TB disease treatment, we defined successful outcomes as cured or treatment completion (treatment was completed but no bacteriologic proof of cure) and unsuccessful outcomes as lost to follow-up (LTFU), death, treatment failure, or no documented outcome (7).
For TBI treatment, we defined successful outcomes as treatment completed and unsuccessful outcomes as LTFU, death, or treatment stopped.When the outcome was treatment stopped, we collected data on reported reasons (8).
We calculated descriptive statistics and conducted bivariate analyses to determine associations between exposure and outcome variables.We used χ 2 tests for categorical variables and t-tests for continuous variables to identify associations between independent and outcome variables.We considered variables with a p value of <0.05 and an estimate range within a 95% CI to be significant.We included all variables with a p value of <0.2 from bivariate analysis in the multivariate analysis.We used logistic regression to control for effect modification and confounders with dichotomous outcomes.We conducted analyses by using SAS version 9.4 (SAS Institute Inc., https://www.sas.com).
A total of 2,672 PDLs were treated for TBI; the median age was 30 (IQR 26-38) years, and most of those treated (2,337 [87.5%]) were men.Of 2,668 PDLs with documentedHIV status, 2,468 (92.5%) were  2).TB is common in Uganda Prisons Service facilities and, despite improvements among the general population, treatment outcomes among PDLs remain suboptimal (6).Renewed efforts are needed to improve treatment outcomes, especially for PDLs who have extrapulmonary infection or laboratoryconfirmed pulmonary TB or who are PLHIVs (9,10).Because of transmission risks within this congregate setting, TPT could be further expanded, including among HIV-negative persons.Unsuccessful outcomes did not differ markedly according to HIV status among patients with TB disease.Reported deaths among PLHIV treated for TBI might be attributed to opportunistic infections or missed TB disease diagnoses (11).
Short prison stays are challenging for successful TB treatment (12).Enhanced referral networks could ensure treatment continuity, including during prison transfers and after release.Strengthened data systems are needed to properly document and report treatment outcomes regardless of release or transfer status.Finally, World Health Organization-recommended short-course treatment regimens for TB disease and TBI could be prioritized for prisons to improve treatment completion (13,14) and documentation, given the frequent transfers, short average stay, and suboptimal continuity of care after release.
The first limitation of our study is that we could not evaluate outcomes among PDLs who transferred out or those without documented outcomes, which could negatively skew results.Second, data limitations precluded analysis of other known risk factors for unsuccessful treatment outcomes (e.g., homelessness, substance abuse, previous imprisonment, presence of cavitary disease) (15).Finally, the concurrent COVID-19 outbreak during the study period, which disturbed health service provisions, could have affected treatment outcomes, limiting generalizability of findings to the years before and after the outbreak.

Conclusions
We found suboptimal treatment outcomes for PDLs with TB disease and TBI in Uganda Prisons Service facilities.Remedial efforts are needed to enhance referral networks to ensure treatment continuity, strengthen data systems for complete outcome documentation, and prioritize short-course treatment regimens.
This activity was covered by a certificate of confidentiality from the US Centers for Disease Control and Prevention and approved by the Uganda National Council of Science and Technology.The Uganda Ministry of Health, Uganda Prisons Service, and US Centers for Disease Control and Prevention provided oversight for data sharing and management.This study was supported by the President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention (cooperative agreement no.NU2GGH001605).Findings and conclusions in are those of the authors and do not necessarily represent the official position of the funding agencies.

Treatment Outcomes for Tuberculosis Infection and Disease Among Persons Deprived of Liberty, Uganda, 2020
DOI: https://doi.org/10.3201/eid3007.230611Wereport that unsuccessful treatment outcomes were 11.8% for tuberculosis (TB) disease and 21.8% for TB infection among persons deprived of liberty in Uganda Prisons Service facilities.Remedial efforts should include enhancing referral networks to ensure treatment continuity, strengthening data systems for complete outcome documentation, and prioritizing short-course treatment regimens.

Table 1 .
Characteristics and treatment outcomes among persons deprived of liberty who had TB disease in Uganda prisons, January- *aOR, adjusted odds ratio; TB, tuberculosis.†Pulmonary TB was confirmed by bacteriologic laboratory tests.‡Data are for a total of 1,116 patients with TB disease who had documented HIV status.

Table 2 .
Characteristics and treatment outcomes among persons deprived of liberty who had TB infections in Uganda prisons, January-December 2020* *aOR, adjusted odds ratio; TB, tuberculosis.